Tricuspid and pulmonary valve guideline published

The British Society of Echocardiography (BSE) is delighted to announce the publication of a new tricuspid and pulmonary valve guideline.

This guideline aims to provide the reader with a theoretical background to the pathological processes involved in right-sided valve disease, and their consequences on cardiac remodelling. It also aims to serve as a didactic, hands-on guide for echocardiography practitioners, including practical advice on image acquisition and optimisation, as well as up-to-date reference values for valve disease quantification. 

Lead author Dr Abbas Zaidi, Consultant Cardiologist at the University Hospital of Wales, Cardiff said, "To our knowledge, this is the first dedicated tricuspid and pulmonary valve guideline that comprehensively covers transthoracic, transoesophageal, 3D, and exercise echo, and introduces the role of allied modalities such as CMR and CT. We hope that the echocardiography community will find this to be an informative and practical addition to the literature."

Whilst the recently published BSE right heart guideline did cover the TV and PV, its primary focus was on the assessment of right ventricular dimensions and function. The intention of our latest guideline is to provide an up-to-date and comprehensive protocol for the echocardiographic assessment of the tricuspid and pulmonary valves in adults. This is a rapidly evolving field, particularly with the advent of percutaneous structural right heart interventions. The importance of conditions such as secondary tricuspid regurgitation is increasingly recognised, and there is a requirement for robust guidance for the accurate and reproducible quantification of right-sided valvular indices. Reference limits are quoted on the basis of the most up-to-date studies and techniques. The role of exercise testing, as well as complimentary imaging techniques such as magnetic resonance and computed tomography, is also described. 

Perhaps the most notable change from previous BSE guidelines is that we have fully integrated 3D echo into the routine assessment of the right-sided chambers and valves, whereas 3D has previously been seen as an ‘optional extra’, used predominantly for the left heart. Three-dimensional echocardiography has provided huge insights into the mechanisms and progression of tricuspid valve disease, and as such is covered in detail within this document. In the present guideline we comprehensively characterise how to obtain 3D datasets of the right heart, how to post-process the resulting data, and we also provide reference values for 3D-derived parameters such as tricuspid vena contracta area. 

As a society, we feel that it is timely for the BSE to transition its guidelines from being descriptive protocols for how to acquire images, towards documents which also educate the reader, and explain the evidence behind what we do. As such, we have included sections on anatomy, ultrasound physics, pathophysiology, and cutting-edge research from around the world, to help inform best practice in the assessment of right-sided heart valve disease. The thresholds in the guideline are concordant with recent BSE guidelines, including the normal reference ranges, right heart and pulmonary hypertension guidelines. The reference ranges described within these papers will now form the basis of questions in accreditation exams, and should also be adopted in day-to-day clinical practice.

We were privileged to have had Professor Luigi Badano, Professor of Cardiology at University of Milano-Bicocca, as senior author on this work. Professor Badano is recognised as one of the world’s foremost authorities on a range of topics including tricuspid valve disease, 3D echo, and the right heart. Professor Badano said, "This guideline will be the first of its kind and will have an international impact."

Read the guideline